impactA PUBLICATION OF THE UNIVERSITY OF CHICAGO CELIAC DISEASE CENTER | www.cureceliacdisease.org | 4th Quarter 2014

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Celiac disease is unique among intestinal inflammatory diseases in that the trigger for inflammation, gluten, is known. This allows effective dietary treatment. Fortu-nately, most individuals with celiac disease have improvement in symptoms and signs (diarrhea or constipation, abdominal gas/bloating/cramps, fatigue and anemia) with-in two weeks of starting a gluten-free diet. Others improve more slowly due to inade-quate dietary education, inability to give up favorite gluten-containing foods, or cost. In adults, complete recovery of inflammation on intestinal biopsy may take five years or longer. Approximately 10% of adults never completely recover, unlike children who have near 100% recovery of intestinal inflammation in the long term. The reason for this slow recovery of intestinal inflam-mation in adults with celiac disease and whether it has any clinical consequence is unknown. In two studies, persistent in-testinal inflammation carried no mortality risk, one study reported a higher risk for lymphoproliferative disorders.

So what is Nonresponsive Celiac Disease? This term applies to the approximately 20% of individuals diagnosed with celiac disease who have persistent symptoms or anemia with or without a positive tissue transglutaminase antibody. The term is somewhat of a misnomer: The most common cause of Nonresponsive Celiac Disease is failure to completely exclude gluten from the diet, and most of these individuals do have improvement in intestinal inflammation compared to their baseline biopsy, suggesting at least partial diet response. In addition, upon careful review, some are found to have an incorrect diagnosis of celiac disease.

Therefore, the first step in assessment for persistent symptoms is evaluation by a registered dietitian knowledgeable in the gluten-free diet. The most common hidden culprits include medications, processed gluten-free food, gluten-contaminated oats, and restaurant meals. If, despite a stricter gluten-free diet, gastrointestinal symptoms persist, further evaluation is warranted. This usually includes a repeat endoscopy with duodenal biopsy, with further testing based on three different categories of patients. 1) Persistent symptoms, intestinal biopsy normal. This indicates that celiac disease is well controlled on diet and either the diagnosis is incorrect or there is another cause of symptoms. The most common other causes include IBS, Constipation due to low fiber in a gluten-free diet, lactose or fructose intolerance and microscopic colitis in those with predominant diarrhea. In patients who have suffered weight loss, superior mesenteric artery (SMA) syndrome should be considered due to loss of fat around the artery that can then compress the duodenum and cause obstruction. 2) Persistent symptoms, mild inflammation/villous atrophy on intestinal biopsy. This may indicate high sensitivity to even trace amounts of gluten and may warrant a trial of a naked gluten- free diet (no oats and no processed or restaurant food). Occasionally it is due to other diseases that can cause intestinal inflammation, such as non-steroidal anti-inflammatory drugs, small intestinal bacterial overgrowth, infection, or co-existent Crohn’s Disease. Sometimes, no

other cause is found and depending on symptoms and degree of inflammation, immunosuppression treatment is considered. 3) Severe symptoms with weight loss and severe intestinal inflammation/ villous atrophy. This situation is rare, and involves 5% or less of adults with Nonresponsive Celiac Disease. These individuals have severe malabsorption and often require intravenous nutrition. Special studies of intestinal lymphocytes are needed to determine the risk for development of T-cell lymphoma. Treatment is with drugs that suppress the immune system or in the latter case chemotherapy/ bone marrow transplant. It is important in older adults to assess for the use of sartan drugs (olmesartan) used to treat hypertension. These drugs can cause severe intestinal

What is Nonresponsive Celiac Disease? By Carol Semrad, MD

Carol Semrad, MD

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On October 11, 2014, nearly 500 people came to the University of Chicago Medicine to get screened for celiac disease. They underwent two tests generously donated by Prometheus Laboratories, the total serum IgA, to measure how much IgA each person has, and the tTg IgA test, to detect the presence of antibodies to celiac in the blood. The celiac screening, which is done once a year, is open to anyone who has symptoms or is at risk for celiac disease, as long as he or she is on a gluten-containing diet. It is a great opportunity to be screened, especially for those whose doctors do not want to test them or whose insurance would not normally cover it.

In addition to the screening, we held a Q & A Panel with four celiac experts from The University of Chicago Celiac Disease Center (Dr. Stefano Guandalini, Dr. Sonia Kupfer, Dr. Tina Drossos and Lori Welstead, MS, RD, LDN). For 90 minutes, attendees asked whatever they wished of the panelists, and learned about all different aspects of celiac and treatment, including questions about diet and nutrition, the psychology around a celiac diagnosis, current research into new treatments and other relevant topics.

Attendees also enjoyed a Vendor Fair. Two Chicago restaurants, Marcello’s, A Father & Son Restaurant and Bountiful Eatery, joined the Vendor Fair this year. We had several new companies participate as well, including Cookies By Design and toosum. In addition, San-J. Crunchmaster, Jewel/Osco, Namaste, Breads from Anna, Rudi’s, Jones Dairy, Delight Gluten-Free magazine and The University of Chicago Food Service team hosted booths. Thanks to all, especially Jewel/Osco, which also donated snacks for those undergoing testing.

Annual Free Blood Screening

inflammation similar to celiac disease, and these patients are often misdiagnosed as having celiac disease.

The good news is that most individuals with celiac disease have resolution of their symptoms and recovery of intestinal inflammation. Even in the Nonresponsive Celiac Disease group of adults, a stricter diet and time was favorable for complete improvement in symptoms and recovery of intestinal inflammation to normal. In the group with persistent mild inflammation and/or villous atrophy, there was no de-crease in mortality in follow up for over 10

years. Little is known regarding persistent mild intestinal inflammation and the risk for bone mass loss, other autoimmune dis-eases, and cancers. Therefore, the goal in therapy remains recovery in symptoms and intestinal inflammation on a strict gluten-free diet. At present, there is no other ef-fective therapy.

REFERENCES 1) Leffler DA, Dennis M, Hyett B et al. Etiolo-gies and Predictors of Diagnosis in Nonrespon-sive Celiac Disease. Clinical Gastroenterol Hepatol 2007;5:445-450.

2) Tuire I, Marja-Leena L, Teea S, et al.

Persistent Duodenal Intraepithelial Lymphocy-tosis Despite a Long-Term Strict Gluten-Free diet in Celiac Disease. Am J Gastroenterol 2012;107:1563-1569.

3) Wahab P, Meijer JWR, Mulder CHH. Histologic Follow-up of People with Celiac Dis-ease on a Gluten-Free Diet. Am J Clin Pathol 2002;118:459-463.

4) Lebwohl B, Granath F, Ekbom A et al. Mu-cosal healing and Mortality in Celiac Disease. Aliment Pharmacol Ther. 2013;37:332-339.

5) Lebwohl B, Granath, Ekbom. et al. Mu-cosal Healing and Risk for Lymphoproliferative malignancy in Celiac Disease. Ann Intern Med 2013;159:169-175.

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Profi le: Cookies By DesignThis year, we were honored to welcome Cookies By Design as a new Care Package Partner and annual Blood Screening sponsor. Cookies By Design is a unique company, founded in 1983 by single mother Gwen Willite, who had an idea, a daughter and a dog. She packed them all up in her pick-up truck and set off for Dallas, from Arkansas, to start her

unusual cookie gift basket business.

Thirty-one years later, Cookies By Design, still a private company, has nearly 100 outlets in 37 states. Over the past few years, its franchisees reported an increase in requests for gluten-free cookie options, so its bakers went to work. Gluten-free cookies presented some special challenges, in particular, making sure they could stay securely on a stick, for the gift basket presentations.

In 2013, Cookies By Design launched its gluten-free line, which is baked in a dedicated facility and shipped to franchises and company-owned outlets. The cookies are decorated in the shops, after employees have received special training on cross-contamination and best practices.

Like all companies, especially those serving a

niche market, the product line

needs to be financially

viable no matter how

great the intention and how deserving

the consumer. While the gluten-free line is

growing, albeit slowly, says company spokesman Jack

Long, “we’re not able to do this just for the love of it, we have to do it for profit”. Customers we spoke with are

doing everything they can to support Cookies By Design and make sure it stays in the gluten-free cookie business for a long time to come. Thanks, Cookies By Design!

Hilary Jericho, MD, has joined The Celiac Center. Dr. Jericho is an assistant Professor of Pediatrics and a pediatric gastroenterologist at the University of Chicago, Comer Children’s Hospital. Dr. Jericho grew up in Connecticut and attended Brown University for undergraduate and medical school in 2006. She completed her pediatric residency at the Children’s Hospital of Pittsburgh of UPMC in 2009, and both her pediatric gastroenterology fellowship at The Ann & Robert H. Lurie Children’s Hospital of Chicago and her Masters of Science in Clinical Investigation at Northwestern University in June 2012. She joined the faculty at the University of Chicago later that year.

Dr. Jericho’s clinical work and research have focused on a combination of cholestatic liver disease, nutrition, functional gastrointestinal disorders, and celiac disease for which she has produced multiple publications and given many presentations. In 2003 she founded and coordinated Fast

Food Facts, a youth nutrition program to help increase children's awareness of exercise, the body, and healthy food choices at home and when visiting fast food restaurants in Providence, RI. She is the recipient of a number of awards, including the 2003 American Medical Student Association National Jumpstart Grant and the 2010 Clinical Departments of Children’s Memorial Hospital (CMMC) and Children’s Memorial Research Center (CMRC) Tuition Scholarship. She has also authored or coauthored a number of peer-reviewed articles and has recently founded the video capsule endoscopy program at Comer Children’s Hospital. She is also specialized in clinical hypnotherapy which she offers as an alternative treatment for functional abdominal pain. She is affiliated with The University of Chicago Celiac Disease Center and gives presentations on celiac disease both locally and regionally. Dr. Jericho lives in Chicago with her husband and two children.

A New Physician at The Celiac Center

Founding Board : Friends of the University of Chicago Celiac Disease Center

Lisa Aiken

Carlyn Berghoff

Susan Blumenfeld

Jennifer Bruns

Jeff Burnham

Jodi Cole

Aimee Eiguren

Lara Field

Carrie Fohrman

Debbie Gordon

Stuart Gordon

Bo Herbst

Kim Koeller

Scott Mandell

Marilyn Meyers

Andrea Moroney

Danielle Mund Mehta

Judy Petrungaro

Hilda Piell

Gail Pierce

Rachel O’Konis Ruttenberg

Bonnie Sclamberg

Lindsay Siens

Mary Margaret Skelly

Nicole St. Pierre

Sueson Vess

Peggy Wagener

Wendy Weil

Pamela White

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For three days in October, The Celiac Center went to Atlanta to attend FNCE, the Food & Nutrituion Conference & Expo, the annual conference hosted by The Academy of Nutrition and Dietetic’s annual conference. We spoke with hundreds of dietitians, and distributed literature for their patients and clinics. We answered questions about our programs and services, and added all these names to our database, so that these practitioners around the world can receive our e-newsletter and other updates and information going forward. Any dietitians who want to be added to our database or to receive postcards to distribute to patients on our Care Package Program and free e-book, Jump Start Your Gluten-Free Diet, can contact us through our website, www.cureceliacdisease.org.

The Celiac Center Goes to the Food & Nutrition Conference & Expo

Preceptorship ProgramTwo weeks ago, The University of Chicago Celiac Disease Center brought together 30 doctors and dietitians from 14 states and four countries for our unique two-day hands-on course on celiac disease. The preceptors attended lectures from celiac experts at The University of Chicago Medicine, attended clinics with patients and participated in robust, interactive case-study sessions. The program not only provides for continuing education credits for medical professionals, but it imparts in-depth knowledge and understanding of celiac disease that graduates can share with their colleagues and better serve their patients back home.

Research Wrap Up

For a full report on research highlights of the past year, please visit our website. In other important areas of research, the Center’s celiac database now has over 800 patients, both pediatric and adult. New patients are added weekly, and it is running in real-time with new data from biopsies, labs, and clinic visits. The database helps researchers and doctors to compare symptoms between pediatric and adult patients, see varying lab and biopsy results over time, establish connections with other autoimmune diseases, and

discern specific patterns that can help guide treatment and research going forward. In addition, The University of Chicago Celiac Disease Center is launching a new study entitled “Optimizing behavioral health among adolescents with Celiac Disease”. It has been reported that patients with celiac disease may have a reduced quality of life, compared to healthy individuals, in part due to the limitations associated with maintaining a gluten-free diet (Lee

& Newman, 2003). The aim of our study will be to assess the quality of life as well as other psychosocial/behavioral factors in children with celiac disease. The data collected will be used to inform a larger study on predictors of adjustment and engagement in optimal behavioral health in late adolescence, a developmental period during which adherence to treatment and dietary restrictions are low.

To learn more, see our 2014 Research Summary.

Research toward a cure is at the forefront of our mission, and as always, Dr. Jabri’s team of investigators are working hard toward that goal.

>Above:

Faculty at the 2014 Preceptorship

Program

Below: Dr. Valentina

Discepolo presents to the attendees

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We are so grateful to The Friends of The Celiac Disease Center who have run events and fundraisers for us throughout the year. This year our Friends have hosted a plethora of fundraising events: a bike ride in New York, a week of Gluten-Free Dinners at Wildfire Restaurants in Chicago, a promotion from Mariposa Bakery in California, and of course, the incredible annual Celiac Skate event in Chicago, scheduled again for February 22, 2015. Just last month, the Liquor Barn in Wheeling, IL, made our Center its charity of choice for its second annual Wine, Spirits and Beer Fest. We thank all our supporters for their hard work in putting together these wonderful events, and we appreciate their dedication to our Center. If you are interested in becoming a “Friend” of the Center by hosting an event to support our work, please contact us via our website.

Friends of The Celiac Disease Center

Top left: Dr. Steve Sclamberg (l), Harlan Kahn, Kiki Koretz (middle row) and Gracie Sclamberg; Top Right: Wildfire Glenview Executive Chef Rodrigo Torres (l), Laura Nessel, Wildfire Restaurants Sales & Marketing Manager and Wildfire Divisional Executive Chef Moreno Espinoza (r); Below: Happy revelers at the Liquor Barn’s Wine, Spirits and Beer Fest.

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Stefano GuandaliniSection Chief The University of Chicago Comer Children’s Hospital, Pediatric Gastroenterology, Hepatology and Nutrition

MEDICAL ADVISORY BOARD

Bana Jabri, MD, PhD

Hilary Jericho, MD

Sonia Kupfer, MD

Lori Rowell, MS, RD, LDN

Carol Semrad, MD

Elizabeth Wall, MS, RD, LDN

STAFF MEMBERS

Stefano Guandalini, MD, Founder & Medical Director

Carol M. Shilson, Executive Director

Ronit Rose, Program Director

Diane McKiernan, Study Coordinator

Trent Eisfeller, Office Assistant

GENERAL OFFICE INFORMATION

5841 S. Maryland Avenue, MC 4069Chicago IL 60637773-702-7593 www.CureCeliacDisease.org Facebook: cureceliac Twitter: @cureceliac

January 25, 2015: 11:30 am Widfire Brunch Lincolnshire. For reservations, please call Shannon or Tina at 847-279-7900. February 22, 2015: Celiac Skate, 12:30-2:30 pm, Centennial Rink, Highland Park. Ticket sales open on Jan. 1—please visit www.regonline.com/celiacskate2015 for more information or to buy tickets. March 28, 2015: The University of Chicago Preceptorship Program presents in Wilmington, NC May 1, 2015: Spring Flours Annual Gala, at Galleria Marchetti, Chicago. More information coming soon! May 16–19, 2015: Digestive Disease Week, Washington, DC. The University of Chicago Celiac Disease Center will be there to share our resources and information with the thousands of gastroenterologists who attend. June 21-24, 2015: The 16th International Celiac Disease Symposium 2015, in Prague, Czech Republic. Many of the Celiac Center doctors will be lecturing and presenting their research at this conference, which is open to all. For more information, visit http://www.icds2015prague.com/. June 7, 2015: The University of Chicago Celiac Disease Center is sponsoring the 2015 Washington DC Gluten-Free Expo, in Bethesda, MD. Visit http://www.dcglutenfreeexpo.com/ for more information. October 3-6, 2015: The Celiac Center will attend the Food & Nutrition Conference & Expo, to connect with dietitians from all over the world.

Calendar of Upcoming Events

MythbusterCeliac only affects the GI tract.Some of the typical symptoms are GI-related, i.e. bloating, diarrhea, constipation and gas. However, physicians are now realizing that an array of other symptoms also occurs. These non-GI symptoms are becoming just as prevalent, if not more so, thank the typical symptoms. They include anemia, recurring headaches, arthritis and osteoporosis.

Our Answer Bank at www.cureceliacdisease.org page is a wealth of information about celiac disease. Please friend us on Facebook and join us on Twitter as well: http://facebook.com/cureceliac and http://twitter.com/cureceliac.

Bakery on Main

Bob’s Red Mill

Breads from Anna

Cabot Creamery

Cookies by Design

Crunchmaster

Delight Gluten Free

Dr. Lucy’s, LLC

Dr. Schär

Enjoy Life Foods

ginnybakes

Jones Dairy Farm

King Arthur Flour

Namaste Foods LLC

Pamela’s

San-J International, Inc

Sevierly Good

Zema’s Madhouse Foods

Thanks to all our partners for the 1,300+ Care Packages they helped provide for newly diagnosed patients all over the US! Please try our partners’ wonderful gluten-free products, and continue to support them. Without them, this program would not be possible.

Care Package Program